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k <br /> �` vr Industry Services Division County Dane J <br /> i t` 11 ''` 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P ill P.O. Box 7162 <br /> 'ti $ •c+ Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Joseph Eugster 052/0510-102-8621-0 <br /> Property Owner's Mailing Address Property Location <br /> 3865 HWY 138 <br /> Govt.Lot i <br /> City,State Zip Code Phone Number NE NE {0 <br /> Stoughton, Wi _--- %+> /., i Section <br /> €' X358 608-279-3502 (circle one) <br /> 11.Type of Building(check all that app ) Lot# T 5 N; R 10 lr W <br /> ®1 or 2 Family Dwelling-Number of Bedro ms 5 1 Subdivision Name <br /> -�. Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of ........ <br /> ❑State Owned-Describe Use CSM Number Cl Village of <br /> 11670 1K Town of Rutland <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A' ®New System ❑Re p lacement S y stem ❑T reatmcnUFloldin g Tank Re p lacement Only 0 Other Modification to Existin g System(ex p lain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ® Mound<24 in.of suitable soil <br /> ❑ Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 750 0.6 12 50 lifig 1663 101.70 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units t o'o <br /> New Tanks Existing Tanks o 0 5 w , 1 I <br /> v v> .y v, w E5 E. <br /> Septic or-iie{durg lank 1600 -- 1600 1 Crest <br /> Dosing Chamber 800 800 1 Crest <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature tdilt/MPRS Number Business Phone Number <br /> Kenneth Haugen ' L' ‘ 2j 6G2 224121 608-205-0238 <br /> Plumber's Address(Street,City,State,Zip Code) ' • �'Q r( <br /> 317 W. Broadway Street Stoughton, Wi 53589 • ,.--� / f03— S-7E_C..f.�L <br /> Vill.County/Department Ilse Only J �(� <br /> Permit Fee Date Issued- ' Issuin ent i ature <br /> ,proved ❑Disapproved $ - / C <br /> 4sof:'ir_ .'- ,,,_ , <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ) <br /> (Al (ifs A'/ 4 t0/07 79/1; g&�&7 FRois- ..._:7y_ E <br /> CP/�1Pik--10r/ s. rL 6--/ Vift Gy 11rt'.D � -le c(i4.422 ?i€,1 i FCt3 4 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t 2 x 11 inches in size <br /> Public Health MDC <br /> SBD-6398(R0313) <br /> Environmental Health <br />